MEASURE #4: Overuse of Barbiturate Containing Medications for Primary Headache Disorders Headache

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1 MEASURE #4: Overuse of Barbiturate Containing Medications for Primary Headache Disorders Headache Measure Description Percentage of patients age 18 years old and older with a diagnosis of primary headache who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis during the 12-month measurement period. Measure Components Numerator Statement Patients who were NOT prescribed barbiturate containing medications related to the primary headache disorder diagnosis* during the 12-month measurement period. *Prescribing a barbiturate containing medication for the primary headache disorders, without a justified exception, is not recommended by current evidence-based guideline recommendations. Clinicians who would have a higher score or percentage of patients that met this measure would be delivering a higher quality of care. Denominator Statement Denominator Exceptions Supporting Guideline & Other References Note: The above list of medications/drug names is based on clinical guidelines and other evidence and may not be all-inclusive or current. Physicians and other health care professionals should refer to the Food and Drug Administration s (FDA) web site page entitled Drug Safety Communications for up-to-date drug recall and alert information when prescribing medications. All patients age 18 years old and older diagnosed with a primary headache disorder*. *Primary Headache: A headache that is not caused by another disease or medical condition. For the purpose of this measure this includes the following types of headache: Migraine: Migraine without aura, migraine with aura, childhood periodic syndromes that are commonly precursors of migraine, retinal migraine, complications of migraine, probable migraine. Tension-Type Headache (TTH): Infrequent episodic TTH, frequent episodic TTH, chronic TTH, probable TTH. Cluster Headache (CH) and Other Trigeminal Autonomic Cephalgias: Cluster headache, paroxysmal hemicrania, short-lasting unilateral neuralgia form headache attacks with conjunctival injection and tearing (SUNCT), and probable trigeminal autonomic cephalgia. Other Primary Headaches: Primary stabbing headache, primary cough headache, primary exertional headache, primary headache associated with sexual activity, hypnic headache, primary thunderclap headache, hemicrania continua, and new daily-persistent headache. Exceptions: Medical exception for prescribing a barbiturate containing medications for primary headache disorder (i.e., use as a last resort for a patient who has failed all other guideline recommended medications for headache or who have contraindications; may be considered for rescue therapy in a supervised setting for acute migraine when sedation side effects will not put the patient at risk and when the risk abuse has been addressed). The following clinical recommendation statements are quoted verbatim from the referenced clinical guidelines or evidence papers and represent the evidence base for the measure: American Academy of Neurology. All Rights Reserved. 29

2 Based on concerns of overuse, medication-overuse headache, and withdrawal, the use of butalbital-containing analgesics should be limited and carefully monitored. (Grade B) 1 Don t use opioid or butalbital treatment for migraine except as a last resort. (No Level of Evidence; Choosing Wisely Recommendation) 2 Any use of barbiturates and opiates was associated with increased risk of transformed migraine after adjusting for covariates. (Not a guideline) 3 Limit and carefully monitor their use (butalbital containing agents) based on overuse, medication overuse headache, and withdrawal concerns. (Level B) 4 1 National Institute for Health and Clinical Excellence (NICE) Headaches: Diagnosis and management of headaches in young people and adults. National Clinical Guideline Centre on behalf of the National Institute for Health and Clinical Excellence (NICE) September 2012; NICE clinical guideline Lander-Gould A, Anderson W, Armstrong M et al. The American Academy of Neurology s Top Five Choosing Wisely recommendations. Neurology 2013; Published online before print February 20, 2013, doi: /WNL.0b013e31828aab14 Neurology /WNL.0b013e31828aab14 3 Bigal ME, Serano D, Buse D, et al Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study Headache. 2008; 48(8): Silberstein SD. Practice parameter: evidence-based guidelines for migraine headache (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology ;55(6): (Updated in 2012 by the AAN) Rationale for the Measure Gap in Care Triptans and ergots are considered first line acute treatments for migraine, not opioids or barbiturates by the US Headache Consortium Guideline. 1 However, barbiturates or butalbital containing agents are prescribed frequently. The use of barbiturates increases the risk of chronic daily headache and drug induced hyperalgesia. 2 One study noted that barbiturate or opioid class of medicine is more likely to be overused among those patients presenting to a tertiary headache center (overused substances: Butalbital containing combination products, 48%; Acetaminophen, 46.2%; Opioids, 33.3%; ASA, 32.0%; Ergotamine tartrate, 11.8%; Sumatriptan, 10.7%; Nonsteroidal anti-inflammatory medications other than ASA, 9.8%; Zolmitriptan, 4.6%; Rizatriptan, 1.9%; Naratriptan, 0.6%. Total of all triptans, 17.8%). 1 Opportunity for Improvement By reducing the use of barbiturate for primary headache disorders there is potential to decrease chronic daily headaches, improve quality of life and reduce headache associated disability. 1Matchar DB, Young WB, Rosenerg J, et al. Multispecialty consensus on diagnosis and treatment of headache: pharmacological management of acute attacks. Available at (accessed November Lipton RB, Buse DC, Serrano D et al. Examination of Unmet Treatment Needs Among Persons With Episodic Migraine: Results of the American Migraine Prevalence and Prevention (AMPP) Study. Headache Jul 23. doi: /head [Epub ahead of print] American Academy of Neurology. All Rights Reserved. 30

3 Measure Designation Measure purpose Type of measure Level of Measurement Care setting Data source Quality improvement Accountability Process Individual Practitioner Inpatient Outpatient visits Emergency Departments Urgent care Electronic health record (EHR) data Administrative Data/Claims (inpatient or outpatient claims) Administrative Data/Claims Expanded (multiple-source) Paper medical record Technical Specifications: Administrative/Claims Data Administrative claims data collection requires users to identify the eligible population (denominator) and numerator using codes recorded on claims or billing forms (electronic or paper). Users report a rate based on all patients in a given practice for whom data are available and who meet the eligible denominator criteria. The specifications listed below are those needed for performance calculation. Denominator (Eligible Population) ICD-9 and ICD-10 Diagnosis Codes: ICD-9 Code ICD-10 Code 346 Migraine G43 Migraine Migraine with aura G43.1 Migraine with aura without mention of with migraine, so stated, without mention of status G Migraine with aura, not, without status G Migraine with aura,, without status without mention of migraine G Migraine with aura, not with migraine, so stated, Migraine without aura G43.0 Migraine without aura without mention of with migraine, so stated, without mention of status without mention of migraine with migraine, so stated, Variants of migraine, not elsewhere classified without mention of G Migraine with aura, with status G Migraine without aura, not without status G Migraine without aura, without status G Migraine without aura, not G Migraine without aura, G43.9 Migraine, unspecified G Migraine, unspecified, not without status American Academy of Neurology. All Rights Reserved. 31

4 with migraine, so stated, without mention of status without mention of migraine G Migraine, unspecified, without status G Migraine, unspecified, not with migraine, so stated, Hemiplegic migraine G43.4Hemiplegic migraine without mention of G Migraine, unspecified, G Hemiplegic migraine, not without status with migraine, so stated, G Hemiplegic migraine, without mention of status without status without mention of G Hemiplegic migraine, not migraine with migraine, so stated, G Hemiplegic migraine, Menstrual migraine G43.8 Other migraine without mention of G Menstrual migraine, not without status with migraine, so stated, without mention of status without mention of migraine with migraine, so stated, Persistent migraine aura without cerebral infarction without mention of with migraine, so stated, without mention of status without mention of migraine with migraine, so stated, Persistent migraine aura with cerebral infarction without mention of with migraine, so stated, without mention of status without mention of migraine G Menstrual migraine, without status G Menstrual migraine, not G Menstrual migraine, with status G43.5 Persistent migraine aura without cerebral infarction G Persistent migraine aura without cerebral infarction, not without status G Persistent migraine aura without cerebral infarction, without status G Persistent migraine aura without cerebral infarction, not with status G Persistent migraine aura without cerebral infarction, with status G43.6 Persistent migraine aura with cerebral infarction G Persistent migraine aura with cerebral infarction, not without status G Persistent migraine aura with cerebral infarction, without status G Persistent migraine aura with cerebral infarction, not with status American Academy of Neurology. All Rights Reserved. 32

5 with migraine, so stated, G Persistent migraine aura with cerebral infarction, with status Chronic migraine without aura G43.7 Chronic migraine without aura without mention of G Chronic migraine without aura, not without status with migraine, so stated, G Chronic migraine without aura, without mention of status without status without mention of G Chronic migraine without aura, not migraine with migraine, so stated, G Chronic migraine without aura, Other forms of migraine G43.8 Other migraine without mention of G Other migraine, not without status with migraine, so stated, G Other migraine, without without mention of status status without mention of G Other migraine, not with migraine status with migraine, so stated, G Other migraine, with status Migraine unspecified G43.9 Migraine, unspecified without mention of G Migraine, unspecified, not without status with migraine, so stated, G Migraine, unspecified, without mention of status without status without mention of G Migraine, unspecified, not migraine with migraine, so stated, G Migraine, unspecified, 784 Symptoms involving head and neck Headache G44.1 Vascular headache, not elsewhere classified R51 Headache 307 Special symptoms or syndromes not elsewhere classified Pain disorders related to psychological factors Tension headache G Tension-type headache, unspecified, not 339 Other headache syndromes Cluster headaches and other trigeminal autonomic cephalgias Cluster headache syndrome, unspecified G Cluster headache syndrome, unspecified, not Episodic cluster headache G Episodic cluster headache, not Chronic cluster headache G Chronic cluster headache, not Episodic paroxysmal hemicranias G Episodic paroxysmal hemicrania, not American Academy of Neurology. All Rights Reserved. 33

6 Chronic paroxysmal hemicranias G Chronic paroxysmal hemicrania, not Short lasting unilateral neuralgiform G Short lasting unilateral neuralgiform headache with conjunctival injection and headache with conjunctival injection and tearing tearing (SUNCT), not Other trigeminal autonomic G Other trigeminal autonomic cephalgias cephalgias (TAC), not Tension type headache unspecified G Tension-type headache, unspecified, not Episodic tension type headache G Episodic tension-type headache, not Chronic tension type headache G Chronic tension-type headache, G Chronic tension-type headache, not Complicated headache syndromes Hemicrania continua G44.51 Hemicrania continua New daily persistent headache G44.52 New daily persistent headache (NDPH) Primary thunderclap headache G44.53 Primary thunderclap headache Other complicated headache G44.59 Other complicated headache syndrome syndrome Other specified headache syndromes Hypnic headache G44.81 Hypnic headache Headache associated with sexual G44.82 Headache associated with sexual activity activity Primary cough headache G44.83 Primary cough headache Primary exertional headache G44.84 Primary exertional headache Primary stabbing headache G44.85 Primary stabbing headache Other headache syndromes G44.89 Other headache syndrome AND CPT Evaluation and Management Service Codes: Outpatient: , (Office or other outpatient visit-new Patient); (Office or other outpatient visit-established Patient); (Office or Other Outpatient Consultation-New or Established Patient); Inpatient: (Initial Hospital Care); (Subsequent Hospital Care); (Hospital Discharge); (Initial Inpatient Consultation). Emergency Department: Urgent care: or American Academy of Neurology. All Rights Reserved. 34

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